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What GAO Found

The Departments of Defense (DOD) and Veterans Affairs (VA), with guidance from the Interagency Program Office (IPO) that is tasked with facilitating the departments' efforts to share health information, have taken actions to increase interoperability between their electronic health record systems. Among other things, DOD and VA have initiated work focused on near-term objectives, including standardizing their existing health data and making them viewable by both departments' clinicians in an integrated format. The departments also have developed longer-term plans to modernize their respective electronic health record systems. For its part, the IPO has issued guidance outlining the technical approach for achieving interoperability between the departments' systems.

Even with the actions taken, DOD and VA did not, by the October 1, 2014, deadline established in the National Defense Authorization Act (NDAA) for Fiscal Year 2014 for compliance with national data standards, certify that all health care data in their systems complied with national standards and were computable in real time. Both departments stated that they intend to do so later in calendar year 2015. Further, the departments' system modernization plans identify a number of key activities to be implemented beyond December 31, 2016—the deadline established in the NDAA for the two departments to deploy modernized electronic health record software to support clinicians while ensuring full standards-based interoperability. Specifically, DOD has issued plans and announced the contract award for acquiring a modernized system to include interoperability capabilities across military operations. In addition, VA has issued plans describing an incremental approach to modernizing its existing electronic health records system. These plans—if implemented as currently described—indicate that deployment of the new systems with interoperability capabilities will not be completed across the departments until after 2018.

The IPO has taken steps to develop process metrics intended to monitor progress related to the data standardization and exchange of health information consistent with its responsibilities. For example, it has issued guidance that calls for tracking metrics, such as the percentage of data domains within the departments' current health information systems that are mapped to national standards. However, the office has not yet specified outcome-oriented metrics and established related goals that are important to gauging the impact that interoperability capabilities have on improving health care services for shared patients. IPO officials said this work is ongoing and that a team is working with DOD, VA, and subject matter experts to identify metrics that would provide more meaningful measures of the impact of increased interoperability. However, the IPO has not identified a time frame for when this team will report its results and when the IPO plans to incorporate these metrics and goals into its guidance. Without ensuring that outcome-oriented metrics and related goals are defined and incorporated into the current approach, the departments and the IPO will not be positioned to assess and report on the status of interoperability-related activities and determine areas that need improvement.

Why GAO Did This Study

DOD and VA operate two of the nation's largest health care systems, serving approximately 16 million veterans and active duty service members and their beneficiaries, at a cost of more than $100 billion a year. For almost two decades, the departments have been engaged in various efforts to advance DOD and VA electronic health record interoperability. Among their most recent efforts, the DOD and VA Secretaries have committed the departments to achieving interoperability between their separate electronic health record systems.

The Consolidated Appropriations Act , 2014, and accompanying Joint Explanatory Statement, included a provision for GAO to review the departments' efforts. GAO evaluated the actions taken by DOD, VA, and the IPO to plan for and measure the progress toward achieving interoperability between the departments' electronic health record systems. GAO reviewed relevant program documents and interviewed agency officials.

What GAO Recommends

GAO recommends that DOD and VA, working with the IPO, establish a time frame for identifying outcome-oriented metrics; define related goals to provide a basis for assessing and reporting on the status of interoperability; and update IPO guidance to reflect the metrics and goals identified. DOD and VA concurred with GAO's recommendations.

For more information, contact Valerie C. Melvin at (202) 512-6304 or Melvinv@gao.gov.

Recommendations for Executive Action

Status: Closed - Implemented

Comments: The Department of Defense (DOD) has established a time frame for identifying outcome-oriented metrics related to the interoperability of health data between DOD and the Department of Veterans Affairs (VA). Specifically, according to the DOD/VA Interagency Program Office (IPO), the office, in conjunction with the departments, developed a Health Outcome-Oriented Metrics Roadmap that describes the process for how DOD and VA intend to identify, define, and measure the impact of interoperability on healthcare outcomes. Further, the IPO completed a proof of concept in October 2016 for measuring and reporting outcome-oriented interoperability metrics and developed a related timeline for implementing the concept in four key four business lines including separating service members/integrated disability evaluation system, patient empowerment, population health, and transitions of care. The implementation projects have staggered start dates, the last of which is planned to begin in November 2017. The projects will run concurrently with completion dates projected between December 2018 and February 2019. By establishing a timeline for identifying outcome-oriented metrics in these key areas, the IPO and the departments have better positioned themselves to report on the progress of interoperability and to ensure accountability for delivering improved outcomes on their healthcare services for service members and veterans.

Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should establish a time frame for identifying outcome-oriented metrics.

Agency Affected: Department of Defense

Status: Closed - Implemented

Comments: The Department of Veterans Affairs (VA) has established a time frame for identifying outcome-oriented metrics related to the interoperability of health data between VA and the Department of Defense (DOD). Specifically, according to the DOD/VA Interagency Program Office (IPO), the office, in conjunction with the departments, developed a Health Outcome-Oriented Metrics Roadmap that describes the process for how VA and DOD intend to identify, define, and measure the impact of interoperability on healthcare outcomes. Further, the IPO completed a proof of concept in October 2016 for measuring and reporting outcome-oriented interoperability metrics and developed a related timeline for implementing the concept in four key four business lines including separating service members/integrated disability evaluation system, patient empowerment, population health, and transitions of care. The implementation projects have staggered start dates, the last of which is planned to begin in November 2017. The projects will run concurrently with completion dates projected between December 2018 and February 2019. By establishing this timeline for identifying outcome-oriented metrics in these key areas, the IPO and the departments have better positioned themselves to report on the progress of interoperability and to ensure accountability for delivering improved outcomes on their healthcare services for service members and veterans.

Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should establish a time frame for identifying outcome-oriented metrics.

Agency Affected: Department of Veterans Affairs

Status: Closed - Implemented

Comments: The Department of Defense (DOD) concurred with our recommendation. As of August 2018, the department has taken actions along with the Department of Veterans Affairs (VA) and the DOD/VA Interagency Program Office (IPO) to define goals as a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' electronic health record systems. Specifically, the DOD/VA IPO issued a Joint Interoperability Strategic Plan (JISP) in February 2018 that includes a set of goals and objectives intended to improve interoperability between DOD, VA, and health data providers by fiscal year 2022. For example, the plan describes: overarching goals such as aligning with industry standards to improve coordination of DOD and VA progress and governance for interagency health data sharing; functional capability goals such as sharing information and data in mechanisms that can support aggregate data analyses and reporting; and technical capability goals such as enhancing technical infrastructure for sharing based on distinct data categories. Goals in the plan are supported by multiple objectives that describe activities or standards employed by the departments related to each goal. Defining these goals provides a basis for measuring progress toward interoperability. As a result of these actions, DOD is better positioned to assess and report on the status of health data interoperability being achieved by the department.

Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should ensure related goals are defined to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems.

Agency Affected: Department of Defense

Status: Closed - Implemented

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation. As of August 2018, the department has taken actions along with the Department of Defense (DOD) and the DOD/VA Interagency Program Office (IPO) to define goals as a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' electronic health record systems. Specifically, the DOD/VA IPO issued a Joint Interoperability Strategic Plan (JISP) in February 2018 that includes a set of goals and objectives intended to improve interoperability between DOD, VA, and health data providers by fiscal year 2022. For example, the plan describes: overarching goals such as aligning with industry standards to improve coordination of DOD and VA progress and governance for interagency health data sharing; functional capability goals such as sharing information and data in mechanisms that can support aggregate data analyses and reporting; and technical capability goals such as enhancing technical infrastructure for sharing based on distinct data categories. Goals in the plan are supported by multiple objectives that describe activities or standards employed by the departments related to each goal. Defining these goals provides a basis for measuring progress toward interoperability. As a result of these actions, VA is better positioned to assess and report on the status of health data interoperability being achieved by the department.

Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should ensure related goals are defined to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems.

Agency Affected: Department of Veterans Affairs

Status: Closed - Implemented

Comments: The Department of Defense (DOD) concurred with our recommendation. As of August 2018, the department has taken actions along with the Department of Veterans Affairs (VA) and the DOD/VA Interagency Program Office (IPO) to update IPO guidance to reflect the departments' goals and objectives, as well as their approach to defining and reporting metrics related to health data interoperability. Specifically, the DOD/VA Joint Interoperability Strategic Plan (JISP), issued in February 2018, includes a set of goals and objectives intended to improve interoperability between DOD, VA, and health data providers by fiscal year 2022. Further, the JISP also describes the IPO's approach to monitoring and evaluating interoperability progress using transactional metrics and outcome-oriented metrics. The approach documented in the IPO guidance supports the departments' continued efforts to work toward improving the extent to which interoperability is being achieved by the their electronic health record systems.

Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should update IPO guidance to reflect the metrics and goals identified.

Agency Affected: Department of Defense

Status: Closed - Implemented

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation. As of August 2018, the department has taken actions along with the Department of Defense (DOD) and the DOD/VA Interagency Program Office (IPO) to update IPO guidance to reflect the departments' goals and objectives, as well as their approach to defining and reporting metrics related to health data interoperability. Specifically, the DOD/VA Joint Interoperability Strategic Plan (JISP), issued in February 2018, includes a set of goals and objectives intended to improve interoperability between VA, DOD, and health data providers by fiscal year 2022. Further, the JISP also describes the IPO's approach to monitoring and evaluating interoperability progress using transactional metrics and outcome-oriented metrics. The approach documented in the IPO guidance supports the departments' continued efforts to work toward improving the extent to which interoperability is being achieved by the their electronic health record systems.

Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should update IPO guidance to reflect the metrics and goals identified.